Provider Demographics
NPI:1124109889
Name:VANDENTOP, ROBERTA NADINE (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:MRS
First Name:ROBERTA
Middle Name:NADINE
Last Name:VANDENTOP
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
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Other - Suffix:
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Mailing Address - Street 1:14807 NW APPLEGATE LN
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-1899
Mailing Address - Country:US
Mailing Address - Phone:503-747-2572
Mailing Address - Fax:
Practice Address - Street 1:1815 SW MARLOW AVE
Practice Address - Street 2:STE 110
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5185
Practice Address - Country:US
Practice Address - Phone:503-296-0918
Practice Address - Fax:503-296-6158
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical